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roda renato PDS 4-20-08

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					OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE

Name: RODA, RENATO Age/Sex: 52/M Address: 231 J. Teresa St., Sta. Mesa, Manila Date of admission: March 23, 2008 Admitting Diagnosis: Space Occupying Lesion probably 1. Abscess 2. Malignancy IHD, AF c, MVR, NIF PTB V Residents in charge: Dr. Gutierrez/ Dimaandal/ Areja Clerk-in-Charge: Drs. Florentino/Ingles

Hospital #: 1811972

Patient Discharge Summary This is a case of a 52 year-old male who was admitted due to headache. History of Present Illness Three weeks prior to admission, patient had headache, 5/10 in severity and non-radiating. He had nausea but no vomiting, no fever. No consult was done. Two weeks prior to admission, condition persisted, had left pelvic pain, consulted private clinic but diagnosis was not recalled by the informant and was given Citicoline. There was accompanying loss of appetite. One week prior to admission, there was persistence of headache and had left sided residual body weakness. He consulted IM-ER at OMMC, diagnosed with HCVD, S/P CVD. CT scan of the head was requested and advised for a follow up at IM-OPD. Two days prior to admission, there was persistence of headache and left sided body weakness, and had nausea. Persistence of symptoms prompted consult, hence admission. Past Medical History S/P PTB treatment from October 2007 to January 2008; stopped due to numbness of extremities (+) HPN – recently diagnosed No allergy, asthma, DM and previous operation Family History (+) PTB, DM - maternal (+) HPN – paternal Personal and Social History 10 pack year smoking history Occasional alcoholic beverage drinker Review of Systems General: has weight loss (about 50% in 3 weeks) HEENT: (-) dizziness, (-) tinnitus, (-) dysphagia, (-) gum/nose bleeding Respiratory: (-) cough, (-) colds, (-) DOB Cardiac: (-) chest pain, (-) PND, (-) no orthopnea, (+) palpitations GIT: no abdominal pain, no vomiting, no melena, no change in bowel movement Genitourinary: (-) dysuria, (-) hematuria, (-) oliguria Endocrinology: (-) polyuria, (-) polyphagia, (-) polydipsia Hema: no easy bruisability Musculoskeletal: (-) myalgia, (-) arthralgia Neurologic: (-) seizure, (-) loss of consciousness Physical Examination: conscious, coherent, not in respiratory distress Vital Signs: BP: 110/70 HR: 64 RR: 17 Temp: 37 C SKIN: no pallor, no cyanosis HEENT: pink palpebral conjunctivae, anicteric sclerae, no alar flaring, no mass, no lymphadenopathies, no neck vein engorgement CHEST AND LUNGS: symmetrical chest expansion, no lagging, no retractions, clear breath sounds HEART: adynamic precordium, PMI 5th LICS MCL, normal rate, regular rhythm, no murmur ABDOMEN: flat, normoactive bowel sound, soft, non tender, no mass EXTREMITIES: full equal peripheral pulses, no edema NEURO: Conscious, oriented to time, place and person CN I – can smell II – pupils 2-3mm constrict III, IV, VI – intact EOM V – (+) corneal reflex; good masseter tone VII – no facial asymmetry VIII – good hearing, intact IX, X – good gag

XI – good shoulder shrug XII – tongue midline Motor Sensory DTR

5/5

4/5

100%

80%

++

++

5/5

4/5

100%

80%

++

++

(+) Babinski – Left (-) Clonus (-) Kernig’s/ Brudzinski

Assessment:

Space Occupying Lesion probably 1. Abscess 2. Malignancy IHD, AF c, MVR, NIF PTB V

Plan: for Admission The patient was admitted to 422 under the service of Drs. Changco/ Gardaya/ Gutierrez/ Torres/ Dimaandal/ Areja and secured consent for admission and management. TPR every shift and recorded, Input and output was monitored and recorded every shift. Patient’s diet was low salt, low fat diet. IVF was PNSS 1L for 12 hours.

Laboratory procedures were requested: CBC c PC, Cranial CT scan, MRI, BUN, Crea, Na, K, AST, ALT, ECG, CXR-PA, UTZ of whole abdomen, sputum AFB for 3 days, CBC c PC, urinalysis, 2D Echo, FBS, Lipid profile Under the following medications: Ceftriaxone 1gram/vial 2 vials every 12 hours ANST Metronidazole 500mg TIV every 6 hours INH +PZA +Rifampin + Ethambutol (Myrin P Forte) 4 tabs P.O. pre breakfast OD Vit. B Complex 1 tab OD Mannitol 100cc TIV every 6 hours Patient was for referral to service consultant and to inform neurosurgery of this admission. Vital signs were monitored every hour and CBG every 6 hours pre meals. She was placed to moderate to high back rest. Urine output monitoring and ICC maintenance. Patient was watched out for fever, hypergylcemia, BP elevation/hypotension, changes in sensorium and progession of neurologic deficit. Course in the wards: On the 1st hospital day, the patient was conscious, coherent, not in respiratory distress, had frontal headache, with dyspnea, nausea and PERTL 2-3mm. Patient’s diet was maintained. IVF: PNSS 1L for 12 hours. The following were requested: BUN, Crea, Na, K, AST, ALT, Lipid profile, FBS, Sputum AFB x 3 days, ESR. He was scheduled for whole abdominal UTZ. He was still for MRI and 2Decho c Doppler. Medication was continued. Tramadaol 50mg TIV q8 RTC was given. He was prescribed with Cinnarazine 25mg tab TID PO. Mannitol and antibiotics were continued. He was referred to the neurology service consultant. Impression was convelic abscess vs. brain malignancy. MRI (cranial) with MRS was ordered. He was placed to moderate to high backrest. VSq2, NVS/GCS q4. Patient was watched out for persistent headache and progression of neurologic deficits. 9:15 pm, patient was referred back to the surgery department regarding the CT findings of SOL on the right frontal area. Contrast-enhanced MRI as previously ordered must be done. On the 2nd hospital day, patient still had headache, nausea, vomiting and dizziness. Patient’s diet was continued with strict precautions. IVF was PNSS 1L for 12 hours. The previously requested labs were carried out and followed up. Patient was still for MRI with contrast. Antibiotics ordered were secured and given to the patient. He was applied to ICC. Patient was placed to moderate to high back rest. Vital signs and Neuro vital signs were monitored every hour. Input and output were monitored. Patient was watched out for seizure, headache and loss of consciousness. On the 3rd hospital day, patient is conscious, coherent and not in cardio-respiratory distress. Has headache and dizziness but no DOB, no cough, no BOV, no vomiting. Patient was maintained on regular diet. IVF was PNSS 1L for 12 hours. Tramadol drip was started: D5W 500cc + 3 drips Tramadol to run for 24 hours. Medication was continued. Patient was still for MRI with MRA, 2Decho with Doppler, sputum AFB for 3 days, FBS and lipid profile and repeat ECG. Salbutamol nebulization prior to collection of sputum in the morning was ordered. Patient was applied for DDF. Patient was placed to moderate to high back rest. Input and output monitoring. Vital signs every 2 hours and NVS/ GCS every 4 hours. Patient was watched out for persistent headache, dizziness and progression of neurologic deficit. On the 4th hospital day, the patient was on Tramadol drip as ordered, D5W 500cc + 3 amp of Tramadol to run for 24 hours. Patient was for referral if with temperature of 39 C to be given with 500 mg TIV, 1 ½ amp every 4 hours was ordered and TSB. Patient was for repeat CBC c PC and urinalysis. Diet was maintained. IVF PNSS 1L for 12 hours and was reinserted to the other site. The previously requested labs wee carried out and followed up. Patient was still for MRI c MRA. Medication was continued. DDF application was followed up again. Patient was placed to moderate to high back rest. Input and output monitoring. Vital signs every 2 hours and NVS/ GCS was done every 4 hours. Patient was watched out for febrile episodes, persistent headache, dizziness and progression of neurologic deficit.

On the 5th hospital day, patient’s diet was maintained. IVF: PNSS 1L for 12 hours. Tramadol drip was maintained as ordered. . Patient was still for MRI with contrast preferably MRA. Medication was continued. Patient was placed to moderate to high back rest. Input and output monitoring. Vital signs every 2 hours and NVS/ GCS was done every 4 hours. Patient was watched out for headache and progression of neurologic deficit. On the 6th hospital day, patient's diet was maintained on DAT with SAP. IVF: PNSS 1L x 12 hours. Tramadol drip was continued at same rate. Schedule for MRI was followed up. and result of ultrasound. Patient was started with Penicillin G 4,000 'u' TIV. Patient was maintained at moderate to high back rest. VSq2 NVSq2. I and O monitoring was maintained. Patient was watched out for neurologic deficit, difficulty of breathing. On the 7th hospital day, patient's diet was maintained diet and IVF. Patient was restarted with Tramadol drip D5W 500cc for 3 days. CBC with PC were repeated. For repeat Na, K, Cl. Patient was under the following medications: Cefuroxime 20 g TIV q8 (if NA Pen G was given 4 MU q4), Metronidazole 500 mg TIV q6, INH, Rifampicin + EMB + PZA, 4 tablets OD 1 hr before breakfast, Mannitol 100 cc q6 TIV, Cennarizine 25 mg tablet TID PRN for dizziness, Vitamin B complex tablet 1 tablet once a day PO, sHift IV Paracetamol to Paracetamol 500 mg tablet q4 PRN for temperature ≥ 38 °C. patient still maintained at moderate to high back rest, VS q2 NVS/GCS q4. patient was watched out for neurological deficits and fever. On the 8th hospital day, patient's diet and IVF were maintained. Patient was reapplied for ICC for antibiotics. Patient only complains of headache and occasional dizziness. Patient is conscious, coherent, and NICRD. Patient is normotensive, afebrile, normal CR and RR. All cranial nerves are intact. Tramadol drip was followed up. Pen G skin test was (+). MRI was scheduled on April 3, 2008 at The Medical City. For repeat BUN, Crea, Na, K. Medications were taken. Patient was still maintained at moderate to high back rest. On the 9th hospital day, patient's diet and IVF were maintained. Medications were also continued. Patient complained of headache and dizziness. No neurological signs were elicited aside from weakness on the left upper and lower extremities. On the 10th hospital day, patient's diet was maintained on low salt, loft fat diet, IVF was maintained. MRI plates were seen awaits official result. Tramadol drip was ordered dose of Mannitol was increased in dose to 100 cc q4. Metronidazole and Cefuroxime was requested to DDF. Moderate to high back rest. On the 11th hospital day, patient's diet and IVF were maintained. MRI result was relayed. Impression: can be intraparenchymal mass with extension abscess are also considered. Result of the official reading of MRI was followed up. patient was requested for referral to surgery for management and validation. Mannitol was continued as previously ordered. Sputum AFB, 2d echo with Doppler, official result of CXR, and 12L ECG were requested. Vital signs were all normal. Patient continued complaining with headache with low grade fever (37.5°C). On the 12th hospital day, patient's diet and IVF were maintained. Tramadol drip and Mannitol were monitored. VS q2 NVS/GCS q4. patient was watched out for neurological deficits and DOB. Same complaints as previous hospital days. Headache and dizziness with occasional low grade fever. Request for AFB was followed up. On the 13th hospital day, patient's diet and IVF were maintained. Tramadol drip and Mannitol were monitored. VS q2 NVS/GCS q4. patient was watched out for neurological deficits and DOB. Same complaints as previous hospital days. Headache and dizziness with occasional low grade fever. Request for AFB was followed up. On the 14th hospital day, patient's diet and IVF were maintained. Tramadol drip and Mannitol were monitored. VS q2 NVS/GCS q4. patient was watched out for neurological deficits and DOB. Same complaints as previous hospital days. Headache and dizziness with occasional low grade fever. Request for AFB was followed up. On the 15th hospital day, patient's diet and IVF were maintained. Tramadol drip and Mannitol were monitored. VS q2 NVS/GCS q4. patient was watched out for neurological deficits and DOB. Same complaints as previous hospital days. Headache and dizziness with occasional low grade fever. On the 16th hospital day, patient's diet and IVF were maintained. Tramadol drip and Mannitol were monitored. VS q2 NVS/GCS q4. patient was watched out for neurological deficits and DOB. Same complaints as previous hospital days. Headache and dizziness with occasional low grade fever. Patient was placed on moderate to high back rest. On the 17th hospital day, patient's diet and IVF were maintained. Laboratories requested were Na. K, Cl. Patient was referred to the Neurosurgery. Tramadol drip and Mannitol were monitored. VS q2 NVS/GCS q4. patient was watched out for neurological deficits and DOB. On the 18th hospital day, IVF, tramadol drip and mannitol were maintained. VS were monitored q1 and NVS q1, as well. Patient was watched out for neurological deficits and DOB. On the 19th hospital day, diet with SAP, IVF, tramadol drip and mannitol were maintained. Patient was placed on moderate high back rest. VS were monitored q1 and NVS q1. On the 20th hospital day, diet with SAP, IVF, tramadol drip and mannitol were maintained. Referral to surgery was followed-up. VS were monitored q4 and NVS q4. On the 21st hospital day, diet, IVF and tramadol drip were maintained. Ciprofloxacin and metronidazole and other medications were continued. Patient was placed on moderate high back rest. Vital signs monitored q4 and NVS/GCS q4. On the 22nd hospital day, patient still experience headache but now with decrease severity. There was no vomiting, no loss of consciousness and no seizure. Diet and IVF were continued. Review of medicine: TDC drip (3 amps TDL + D5W 500cc x 10ugtts), ceftriaxone 2 mg TIV q12, Metronidazole 500mg TIV q6, decrease mannitol 100cc q8, Myrin P forte tab 4 tab OD before breakfast, Vit B complex 1tab OD, Cinnarizine 25mg/tab TID and Paracetamol 500mg tab 1 tab for temp >38. Patient was for referral back to surgery for the biopsy of the lesion. Vital signs montored q2 and NVS q2. On the 23rd hospital day, diet was maintained with aspiration precautions. Tramadol drip was continued as ordered. IVF was PNSS 1L for 12 hours. Medications were continued. Patient was placed to moderate to high back rest. Patient was referred to neurosurgery for evaluation and management of cerebral mass lesion. Patient was advised to continue medical plan and antibiotics. No immediate neurosurgical intervention was done. Vitals were monitored every 4 hours, neuro vitals every 4 hours and urine output was monitored. On the 24th hospital day, diet was maintained with aspiration precautions. IVF was PNSS 1L for 12 hours. Tramadol drip: D5W 500 cc + 3 drops Fructose to flow for 24 hours was continued. Mannitol was continued as ordered. Patient was placed to moderate to high back rest. Input and output monitoring was done. Vitals were monitored every 4 hours and neurovitals every 8 hours. On the 25th hospital day, patient had headache, dizziness and vomiting. BP was 120/80, CR was 82, RR was 22 and temp was 36.7. Diet was maintained with precautions. IVF was PNSS 1L in 12 hours. Tramadol drip was discontinued. Patient was for repeat cranial MRI. Medications were continued. Tramadol 50 mg TIV was given for pain. Cinnarazine 25 mg was given every 8 hours for dizziness as ordered. Patient was placed in moderate to high back rest. Input and output monitoring was done. Vitals were monitored every 4 hours and neurovitals every 4 hours. On the 26th hospital day, diet was maintained with aspiration precautions. IVF was PNSS 1L for 12 hours. Medications were continued. Patient was referred back to neuro surgery consultant. Patient was placed in moderate to high back rest. Input and output monitoring was done. Vitals and neurovitals signs were monitored every 4 hours. On the 27th hospital day, diet was maintained with aspiration precautions. IVF was PNSS 1L for 12 hours. Patient was still for repeat cranial MRI. Patient was also for repeat Na and K. Medications were continued. Patient was started on Streptomycin 2 gms TIV three times a week to be given every other day. Tramadol drip 50 mg TIV every 8 hours for pain. Patient was placed in moderate to high back rest. Vitals and neurovitals signs were monitored every 4 hours.

On the 28th hospital day, the patient has headache, dizziness, inability to open eyes, responds to questions with nods. There was spontaneous movements. Diet was maintained with strict aspiration precautions. IVF to follow was PNSS 1L in 12 hours. Mannitol drip was increased to 100 cc every 4 hours. Medications were continued. Patient was placed in moderate to high back rest. Strict input and output monitoring was done. Vitals were monitored every hour and neurovitals every 4 hours. CBG monitoring was done and recorded at bedside without fail. On the 29th hospital day, the patient was drowsy. Patient has spontaneous movement. Diet was maintained with strict aspiration precaution. IVF was PNSS 1L in 12 hours. Mannitol was continued 100 cc every 4 hours. Review of medications: 1. Ceftriaxone 2 gms TIV every 12 hours 2. Metronidazole 500 mg TIV every 6 hours. 3. Cinnarazine 25 mg tablet TID PRN for dizziness 4. Paracetamol 500 mg tab PRN for temp equal to or greater than 38.5 5. INH + Rifampicin + EMB + PZA, 4 tablets OD before breakfast 6. Streptomycin 2 gms TID every other day (3x/week) 7. Vitamin B complex 1 tablet OD 8. Captopril 25 mg tab 1 tablet TID PO Patient was started on Tramadol drip, 3 amps Tramadol in D5W 500 cc to run for 24 hours. Vitals were monitored every and neurovitals every 4 hours. Hematology CBC + Diff. Count Normal Values WBC Neutrophils Lymphocytes Monocytes Eosinophils Basophils RBC Hgb Hct MCV MCH MCHC RDW Platelet ESR 4.8-10.8 x 109 /L 55-57 20-30% 0-7% 0-3% 0-1% 4.0-20 x 1012 /L 12-16g/dl 37-47 % 80-90 fL 27-31 32-36 11.5-15.5 150-400 x 10^9/L 0-10 mm/hr 3/23/08 8.4 60.5 30.1 6.9 2.2 0.3 4.81 14.1 41.6 86.5 29.3 33.8 12.1 310 3/30/08 6.1 64.2 21.8 11.2 2.8 0.0 4.02 12.3 35.1 87.2 30.6 35.1 12.3 269

Clinical Chemistry Test Name HDL Triglycerides Lipase Uric Acid Cholesterol LDL BUN Creatinine Na K Cl AST ALT Glucose Normal Values 0.91-1.56 mmol/L 0.34-1.70 mmol/L 23-300 U/L 0.11-0.43 mmol/L 4.20-5.20 mmol/L 1.10-3.80 mmol/L 2.78-7.64 mmol/L 44-106 umol/L 135-145 mmol/L 3.80-5.50 mmol/L 96-108 mmol/L 3/24/08 3/27/08 0.76 low 1.10 4/04/08 4-9-08

4.86 3.6 4.4 62.31 123 4 19 20 low 3.90

123 4.0 95

122 4.1 114

Blood Typing FORWARD TYPING Anti A postive negative Anti B Positive RH typing

Urinalysis

Physical Color Transparency Microscopic Epith. Cell Mucus thread Amorph urates Amorph phosphates Pus cells Erythrocytes Cast Chemical Albumin Sugar Sp. Gravity pH

3/23/08 Dark yellow Slightly turbid Few Many Few

4/01/08 Straw Clear Few Few Few

0-1/hpf 2-4/hpf None Negative Negative 1.020 6.0

1-2/hpf 0-1/hpf

Negative Negative 1.015 7.0

Radiology CT Scan Head with Contrast 3/19/08 Chief complaint: Mild stroke Non-contrast and intravenous-contrast enhanced axial CT images of the head reveal the following findings: At least 3 well-demarcated ovoid hypodense foci with hyperdense and intensely enhancing rims are the right frontal lobe measuring 2.33 x 2.43 x 2.48 cm (largest and abuts the frontal horn of the right lateral 1.57 x 1.77 x 1.52 cm and 1.15 x 1.06 x 1.01 cm. Frond-like perilesional edema is evident with associated effacement of the ipsilateral frontal and sperior parietal cortical sulci and loss of the gray-white matter inter right caudate nucleus is displaced posteriorly. There is compression of the frontal horns of both lateral ventricle as well as tightness of the third and posterior horn of the right lateral ventricle as well as the right Sylvian fissure. Subtalcine shift to the left is also observed measuting 1.01 cm from the midline. The rest of the ventricles are normal in sizes and configuration. The basal cisterns are intact. The sella turcica and the pineal gland are not unusual. The included paranasal sinuses, petromastoids,orbits and bony calvaria are unremarkable. Impression: Rim-enhancing right frontal lobe nodular lesions with perilesional vasogenic edema and mass effects, as described. Considerations include metastasis, abscess formation and a primary brain neoplasm such as gliomas. Contrast-enhanced MRI and clinical correlation suggested for further evaluation. Ultrasound of whole abdomen 3/25/08 Impression: Cholecystolithiasis Normal Sonologic Findings of the Liver, Spleen, Pancreas, Kidneys and Urinary Bladder. MRI 04/02/2008 Right lobe abscess with ventriculitis primarily considered. Tuberculoma or cystic neoplasm are differential diagnoses.


				
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